白袍恐懼症

Nephrolithiasis

INTRODUCTION 

Peak incidence age 30 - 60: 一般輸尿管結石較多。 

Classic symptoms: renal colic and hematuria(多是microscopic hematuria).

ETIOLOGY 

Struvite: 和UTI有關，稱為infection stone(長得快、大)；常見的菌種為Proteus和K.P.菌，Pseudomonas等，這類細菌含有酵素urease，可將尿液中的urea分解成NH4+使尿液呈鹼性，而鹼性環境易使磷酸鹽結晶，產生磷酸銨鎂結石。感染若未有效治療，結石會越長越大，形狀似鹿角，故稱為Struvite stone。

→治療方式：拿掉石頭、酸化尿液、給抗生素

Theory

1.    Supersaturation: 溶質(eg, calcium, oxalate) 濃度過高所造成。 

2.    Renal medullary interstitium

Risk factors 

-A history of prior nephrolithiasis (五年有一半復發)

-family history(三倍)

-enhanced enteric oxalate absorption (eg, gastric bypass procedures, bariatric surgery, short bowel syndrome)

-HTN(2倍), diabetes, obesity, gout, and excessive physical exercise (including marathon running): 增加尿液中晶體形成

- Low fluid intake

- persistently acidic urine(eg,chronic diarrheal states: 因為腸液流失)

- upper UTI

-drug: indinavir, acyclovir, sulfadiazine, and triamterene

Symptoms 

renal colic pain: the most common symptom and varies. Paroxysms(related to movement of the stone in the ureter and associated ureteral spasm) of severe pain usually last 20 to 60 minutes. Pain is thought to occur primarily from urinary obstruction with distention of the renal capsule.

The site of obstruction determines the location of pain.

=>Upper ureteral or renal pelvic obstruction: flank pain or tenderness.

=>Lower ureteral obstruction causes pain: radiate to the ipsilateral testicle or labium.

The location of the pain may change as the stone migrates. Many patients can predict whether the stone has passed through the ureter.

Hematuria: 多為 microscopic hematuria, 但有15%patient 不會出現 hematuria

若是gross hematuria: 小心TCC

If acute, unilateral flank pain, hematuria, and a positive plain film of the abdomen =>90% with a stone.

Other 

nausea, vomiting, dysuria, and urgency. (The last two complaints typically occur when the stone is located in the distal ureter.)

Complications

renal obstruction, which could cause permanent renal damage if left untreated.

Staghorn 若是bilateral 又長期不治療可能會導致 renal failure.

DIFFERENTIAL DIAGNOSIS 

kidney bleeding =>clots(+).

glomerular bleeding =>clot (-)renal colic(-).

Pain+ hematuria=>benign etiology: cysts, stone

Painless hematuria=>suspect tumor

• RCC=> clots(+)colic(rarely)
• ectopic pregnancy=>ultrasound
• aortic aneurysm
• Acute intestinal obstruction or appendicitis => colic(+) hematuria(-).

DIAGNOSIS 

clinical presentation +radiologic tests: KUB, IVP, ultrasonography, and most commonly, non-contrasted helical CT scan.

按先後順序：

KUB: 5~10% radiolucent stone 或stone 太小、角度不好、被腸氣擋住者看不到

=>IVP: 可確診，但renal function normal 才能做

=>echo: Echo對renal stone的偵測比較好，在ureter 的stone容易被腸氣擋住，但若看不到ureter 有stone而腎臟卻有hydronephrosis的話，也可間接證實阻塞的存在。

=> non-contrasted helical CT scan

Treatment

Many patients with acute renal colic can be managed conservatively with pain medication and hydration until the stone passes

1.      Analgesia： NSAIDs or opioids. NSAIDs should be stopped three days before anticipated shock wave lithotripsy to minimize the risk of bleeding. Standard doses of opiates will relieve pain in those who do not respond to NSAIDs.

2. Hospitalization：病人有很厲害的fever, pain等症狀才住院

3. Decompression for Pyonephrosis：若是obstruction造成pyonephrosis，沒有drainage出來光打antibiotics是沒有用的，繼續拖下去腎功能變差→腎發炎→sepsis。這是要馬上decompression的急症，臨床上就是放導管或進刀房用輸尿管鏡把石頭打碎拿出來。

4. Expectant therapy：簡單來說，就是預測病人自己會好，只做pain medication 和hydration(150ml/hr)。if stone < 4mm，多喝水有95%會自行排掉。

5. medical therapy: antispasmodic agents, calcium channel blockers, and alpha blockers(促使distal ureter 擴張), which have been used in combination with or without steroids.

6. 外科手術(但開刀ureter會形成scar→ureter stenosis，更易卡石頭。)

(1). Indications：

-large stone(>6mm)

-unremittent pain

-infection

-loss of renal function.

(2). Noninvasive surgery(0.5~2cm結石)：ESWL、URSM

ESWL（Extracorporeal Shock Wave Lithotripsy）體外震波碎石術

-利用體外震波經過軟組織把石頭打碎，中途最好不要經過骨頭，因此對於腎臟或者上段ureter 的stone較有效。

-平均而言1 cm 的石頭ESWL要打1~2次，再大一點的石頭則較果不好。

-任何部位之尿路結石，接受SWL治療後，如果X光片顯示結石並未被明顯擊碎(disintegration)，不建議再次使用SWL治療，應該採取其他治療方式。

-highly effective for uric acid and calcium oxalate dihydrate stones

-most stone fragments pass within 2 weeks

-cystine, calcium oxalate monohydrate and calcium phosphate dehydrate stones are relatively resistance to shock waves

-not the ideal modality for the management of complex calculi (large or hard calculi, stones located in a caliceal diverticulum, or in patients with complex renal anatomy)

-complications: renal bleeding/hematoma, smaller stone => ureter obstruction => infection

URSM（Ureterorenoscopic Stone Manupilation, 經由輸尿管鏡，利用雷射、電擊等各種方式來把石頭打碎或夾出來）

-多用於處理ureter中下段的石頭

-double J stent placed to prevent ureteric obstruction and pain from ureteral edema

(3).Minimally invasive：PCNL(大於2cm結石)
PCNL（percutaneous nephrolithotomy；經皮膚做一個腎臟造口後，將石頭取出來）

Indications

 -Large (>2 cm in diameter) or complex calculi (filling the majority of the intrarenal collecting system, such as staghorn calculi)

 -Cystine stones (relatively resistant to SWL)

 -Anatomic abnormalities, including horseshoe kidneys or UPJ obstruction

 -Stones within caliceal diverticula

(4). Open surgery

Indications:

 -failure of endoscopic stone removal

 -complex(staghorn) renal calculi

 -complex renal/ureteral anatomy or morbidly obesity

<附註:泌尿醫學會所列之治療方針>

輸尿管結石之治療方針

腎結石之治療方針